Ira R. Katz, M.D., Ph.D.
Good morning Mr. Chairman, thank you for this opportunity to speak about multiple diagnoses and specifically about the principle that Post Traumatic Stress Disorder (PTSD) frequently coexists with other mental health conditions.
Multiple Mental Health Problems
As of the end of the first half of FY 2007, almost 720,000 service men and women have separated from the armed forces after service in Iraq or Afghanistan, and over 250,000 have sought care in VA. About 95,000 received at least a preliminary mental health diagnosis. Among these, PTSD, experienced by over 45,000 or 48 percent is the most common.
The average veteran with a mental health problem received approximately 1.9 diagnoses. There could be several reasons. First, injuries of the mind, like injuries of the body can be non-selective. Depending upon psychological, physiological, or genetic vulnerabilities, the same stress and trauma can give rise to multiple conditions, for example PTSD and depression or panic disorder. Second, the disorders may occur sequentially. Some veterans with PTSD may try to treat their own symptoms with alcohol and wind up with a diagnosis related to problem drinking. Third, some pre-existing mental health conditions like milder personality disorders may be quite compatible with occupational functioning, even in the military, but may increase vulnerability to stress-related disorders like PTSD or depression.
How does VA deal with this problem?
VA has intensive programs to ensure that mental health problems are recognized, diagnosed, and treated. There is outreach to bring veterans into our system, and once they arrive, there is screening for mental health conditions. For those who screen positive for mental health conditions, the next step is a comprehensive diagnostic and treatment planning evaluation. In this, the question is about what is causing the veteran’s suffering or impairment, and what can be done about it. If someone screens positive for symptoms of PTSD, we are interested in whether or not they, in fact have PTSD. But we are also interested in whether or not they have depression, or panic disorder, or problem drinking, or other problems. Which do we treat? We treat them all. Or more significantly, we treat the person, not his or her labels.
Clinical science has advanced dramatically since the Vietnam War. We now know how to diagnose PTSD, and how to treat it. Accordingly, we are hopeful that we can prevent the lasting suffering and impairments that occurred after that war. There is a firm evidence-base for several classes of treatment for PTSD, both psychopharmacological or medication based and psychotherapeutic or talk/behavior based. Specifically, several of the antidepressants that act on the neurotransmitter serotonin have been found to be effective and safe for the treatment of PTSD, and many other medications are currently being studied. Two specific forms of cognitive behavioral therapy, prolonged exposure therapy and cognitive processing therapy appear to be even more effective than the medications, and VA is currently developing high throughput training programs to make them increasingly available within our medical centers, clinics, and Vet Centers. In addition, there is increasing evidence for the effectiveness of psychosocial rehabilitation. For veterans for whom there may be residual symptoms after several evidence-based treatments, treatment is available to help them function in the family, in the community, or on the job.
Given that there are a number of effective treatments, how do we decide which to provide?
Actually, the question should be which to offer first and which comes next. The first treatments are usually offered on the basis of both the provider’s judgment and the patient’s preference. However, we monitor treatments and outcomes, and if the first doesn’t work, we modify it.
What happens when patients have more than one condition? The choice of what to treat first depends on the severity of the conditions, the provider’s judgment, and the patient’s preferences. Plans must allow for combinations or sequences of treatments, as appropriate following Clinical Practice Guidelines or other sources of guidance.
There may have been a time in the past when coexisting conditions may have been barriers to care, when it was hard to treat people with PTSD and alcohol abuse because PTSD programs required people to be sober, and substance abuse programs required them to be stable. This no longer occurs. In fact, there are now evidence based strategies for beginning PTSD and substance abuse treatment simultaneously. One approach, called Seeking Safety was developed in the VA, and is being disseminated broadly.
It may be difficult to diagnose personality disorders in the face of PTSD or other mental health conditions. For patients with relevant symptoms, the clinical approach in VA is to treat the PTSD first. A subsequent step would be evaluate what symptoms or impairments remain, and to plan treatments accordingly.
The message I want to deliver in this hearing is that treatment for PTSD can work. For veterans or others with multiple conditions, treatment may be a multistage process beginning with an evidence based intervention for the most severe of the patient’s conditions, and continuing in a way that depends upon the outcome. Overall, the message should be cautiously optimistic.
Thank you for this opportunity to testify. I will be pleased to answer any questions you may have.